My mother had a stroke early on Tuesday morning. It robbed her of the ability to move her right side, swallow and talk.
She had long been struggling with dementia and had become a small and mostly absent person. Gone was the campaigner for peace, who has survived the London blitz, helped set up the UN after the war, become a passionate educator and a mother of three, who marched against the Iraq war when she was 70 and wore a CND peace badge until she didn’t know what it meant anymore. Many people have written about dementia, but until you watch how the disease slowly and terribly diminishes someone you love day by day it is hard to really understand.
We had found a copy of an advance directive my mother had written and signed in 1997 some weeks previously when going through her papers and bills. It made things easier. It was very clear. Nothing heroic and “if I get dementia definitely no treatment for infections or other significant illness”. So we kept her at home. The staff at the extra care flats where she lived were brilliant. They cared. They kept her comfortable and spoke with tenderness and caring as they washed and turned her.They took care of us too. They stayed beyond their normal shifts and volunteered to sit with her to cover some of the night time so that we could sleep so only people my mother knew would be there if she woke distressed. As my sister said in her euology they truly are "the Angels of Rosemary Court".
We had moved her to a different general practice after problems with the previous practice who had shipped her into hospital unnecessarily and never seemed able to give her any continuity of care over the 10 years she was a patient there. The new practice, despite taking over her care at such a difficult time were fantastic, they listened. They immediately assigned her to one GP (because that is what they do for everyone) who explained to me how to contact her and what to do when she wasn’t there. They visited her before the stroke even though we hadn’t requested a visit, to get to meet her and assess her. They visited her after the stroke and were respectful of my mother’s wishes. They were supportive but unobtrusive. They contacted the nursing teams, out of hours, and the carers in the building. They were in daily contact with us throughout. They were exactly what a general practice should be.
The community nurses were great. They responded quickly always, came regularly and when promised, managed her care with gentle kindness and sensitivity both in hours and out of hours. Their expertise meant she was peaceful and comfortable for all but a few hours when we struggled to control excessive secretions but in the end sorted that too.
My mother died peacefully 6 days after her stroke. She was surrounded by her family, her photos and diaries and memories. We nursed her and when she roused she knew we were there at her side. We told stories about her life, read her diaries, looked at old photos and we became reacquainted with the person she had always been before old age had diminished her: the bright, articulate, opinionated, fiercely loving sometimes difficult woman who was my mother. I don’t think we would have had that if she had died in a hospital bed in the hurly burly of an acute ward. It was a gift to have those days with her.
We were given that gift by those who helped us care for her, the carers, the nurses, the GPs.
Much is written about the NHS and the social care. How it fails, how it needs to do better. I have written about what goes wrong too. I think though it is important to remember that there is so much good that goes unheralded in the press: the care given every day to the most vulnerable and frail. Given generously without expectation of thanks. Individuals who go far beyond what they HAVE to do because they know it is the right thing to do. They are there because they care in a genuinely authentic way as an individual, not just a professional.
So thank you to all the unsung heroes of the caring professions!
I am very grateful to them all and proud of a service that can facilitate such a dignified and gentle end.
Wednesday 31 December 2014
Tuesday 18 November 2014
transformation.. .transformation...transformation....
Have you noticed that everywhere you look in the NHS nowadays everything is “transforming” it is the latest overused buzz word…. What does it really mean? It isn’t some magical process that comes along and changes everything overnight then goes away again… our experience of real redesign and improvement of complex interdependent services is much more about a series small steps leading to an ambitious goal…
Take emergency ambulances… We had a problem. We are a large rural area and our 8 minute response times for Red 1and2s ( emergencies) languished around the mid 50% for years and years. The only answer seemed to be investment in more ambulances but most of the time they would be doing nothing…. There had to be another way..
So working with our ambulance service we looked at a series of other measures… some really simple.
.
moving where ambulances stand and wait… for example :from the station up a hill above the only set of lights in town to the local co-op on the other side of the lights.. an average of a minute saved on trips up the dale…
A formal arrangement with local practices to take over responsibility for cases where the paramedics don’t feel a 999 call patient needs to be taken to A&E but could be given more appropriate care by their general practice…
Paramedics working in primary care.. developing skills.. providing home visits..the next stage of which is a paramedic working out of our local A&E….
Where has this got us.. well this month our Red1/2 response was up to 72% AMAZING!
The next step is to tackle GP urgents…these are calls for ambulances GPs make when they have been out to see a patient at home and decide they need to be admitted to hospital.
GPs usually visit patients who request visit after morning surgery is finished . Some of those will be sent into hospital for tests , investigations and treatment. We discussed with our GPs whether they could arrange to visit patients earlier in the day so patients who needed to be admitted could be sent in earlier to allow the hospital to investigate and treat them on the day they arrive and possibly get home the same day. The GPs felt the patient would get a better service and would be less likely to be admitted, if they were seen by their own GP who knew them and their case than from a visiting duty doctor from the practice
So if they couldn’t be seen sooner, we needed to get them into hospital quicker. If they are very unstable then obviously they need to use the 999 system but for those who are unwell but don’t require emergency transport an ambulance is booked to take them into hospital in a maximum of 4 hours. Sometimes, if there is a lot of emergency activity going on in the area the service may phone back and ask for an extension to that. So it can take hours for patients to get into hospital. They are at home with their families worrying, expecting any moment that the ambulance will come. The hospital is waiting for them to come… if the hospital is a long way away it can take up to 6 hours for them to actually get there…Although some patients are transported by non emergency ambulances much of the time the system relies on the 999 ambulances to do the GP urgent calls. This then reduces the ambulances available for 999 calls.
We wanted to change this. So ,with some of our system resilience money we are running a proof of concept pilot partnering with an organisation called 365response to provide an alternative to our usual ambulance service. They are a public/private partnership who have done all the ground work to develop a safe ,high quality service specification and develop the market. We then did a mini tendering exercise with providers already preselected by them. The new service is manned by emergency care assistants who have more skills than standard PTS drivers but less than paramedics
Our GP practices have a new decision tree which allows them to select the appropriate mode of transport( Paramedic ambulance/ new service ambulance/ own transport) for the patient based on their clinical condition. The new service has a target time of 2 hours from call to arrival at scene.
In the first week: 11 GP Urgent patients were conveyed through the new transport pathway- all safely and with excellent response times and total call cycle times from booking to the patient's arrival at their care destination in less than 2hrs.
Every time a patient is referred to the new service this generates at least 2 hours of additional A&E 999 ambulance resource back into the emergency service and thereby available to respond to our 999 emergency calls. Therefore last week around 22 hours of additional emergency ambulance time was available to YAS across our patch. The medical teams at the hospital have already noticed that paitents are arriving earlier giving them the chance to instigate treatment sooner and hopefully get them home sooner. A win win!
It is early days but it looks really good.
Take emergency ambulances… We had a problem. We are a large rural area and our 8 minute response times for Red 1and2s ( emergencies) languished around the mid 50% for years and years. The only answer seemed to be investment in more ambulances but most of the time they would be doing nothing…. There had to be another way..
So working with our ambulance service we looked at a series of other measures… some really simple.
.
moving where ambulances stand and wait… for example :from the station up a hill above the only set of lights in town to the local co-op on the other side of the lights.. an average of a minute saved on trips up the dale…
A formal arrangement with local practices to take over responsibility for cases where the paramedics don’t feel a 999 call patient needs to be taken to A&E but could be given more appropriate care by their general practice…
Paramedics working in primary care.. developing skills.. providing home visits..the next stage of which is a paramedic working out of our local A&E….
Where has this got us.. well this month our Red1/2 response was up to 72% AMAZING!
The next step is to tackle GP urgents…these are calls for ambulances GPs make when they have been out to see a patient at home and decide they need to be admitted to hospital.
GPs usually visit patients who request visit after morning surgery is finished . Some of those will be sent into hospital for tests , investigations and treatment. We discussed with our GPs whether they could arrange to visit patients earlier in the day so patients who needed to be admitted could be sent in earlier to allow the hospital to investigate and treat them on the day they arrive and possibly get home the same day. The GPs felt the patient would get a better service and would be less likely to be admitted, if they were seen by their own GP who knew them and their case than from a visiting duty doctor from the practice
So if they couldn’t be seen sooner, we needed to get them into hospital quicker. If they are very unstable then obviously they need to use the 999 system but for those who are unwell but don’t require emergency transport an ambulance is booked to take them into hospital in a maximum of 4 hours. Sometimes, if there is a lot of emergency activity going on in the area the service may phone back and ask for an extension to that. So it can take hours for patients to get into hospital. They are at home with their families worrying, expecting any moment that the ambulance will come. The hospital is waiting for them to come… if the hospital is a long way away it can take up to 6 hours for them to actually get there…Although some patients are transported by non emergency ambulances much of the time the system relies on the 999 ambulances to do the GP urgent calls. This then reduces the ambulances available for 999 calls.
We wanted to change this. So ,with some of our system resilience money we are running a proof of concept pilot partnering with an organisation called 365response to provide an alternative to our usual ambulance service. They are a public/private partnership who have done all the ground work to develop a safe ,high quality service specification and develop the market. We then did a mini tendering exercise with providers already preselected by them. The new service is manned by emergency care assistants who have more skills than standard PTS drivers but less than paramedics
Our GP practices have a new decision tree which allows them to select the appropriate mode of transport( Paramedic ambulance/ new service ambulance/ own transport) for the patient based on their clinical condition. The new service has a target time of 2 hours from call to arrival at scene.
In the first week: 11 GP Urgent patients were conveyed through the new transport pathway- all safely and with excellent response times and total call cycle times from booking to the patient's arrival at their care destination in less than 2hrs.
Every time a patient is referred to the new service this generates at least 2 hours of additional A&E 999 ambulance resource back into the emergency service and thereby available to respond to our 999 emergency calls. Therefore last week around 22 hours of additional emergency ambulance time was available to YAS across our patch. The medical teams at the hospital have already noticed that paitents are arriving earlier giving them the chance to instigate treatment sooner and hopefully get them home sooner. A win win!
It is early days but it looks really good.
Thursday 2 October 2014
More about Mum...
As I battled through Friday I definitely felt a blog coming on!
I have written about my mum in the past. Yes, she is only one patient with her own story but so often it seems to me to reflect the bigger issues we face as we try to sort out the system and make it better.
On Friday morning my mother fell. Not a big fall but enough to worry the carers who do such a good job day to day and cope with her increasing confusion and distressing incontinence with sensitivity and kindness. They phoned her GP surgery. This is the surgery that tells you on the opening recorded message how busy they are. The same surgery where a receptionist told me a few weeks ago that the letter informing me of my mothers named GP didn't actually mean anything real and was just a "government initiative"
The duty doctor responded to the visit request. She has been in the practice less than a month. She clearly hadn't read my mothers notes: Did not know about her frequent falls, her previous admissions ( all unnecessary) her recent change in medication. more importantly she didn't have any idea about her usual level of confusion What did she do? She summoned an ambulance and sent her into hospital
My mother was no more unwell than she is every day There was no emergency. She tried to call me once, but I was in a meeting and had my phone on silent. By the time I phoned back it was too late. The NHS machine was already in motion. but why? Because she couldn't be bothered to find out more, and wait to see how the day unfolded. It was laziness justified by business. My mothers named doctor was in the practice that day. She has seen her once but because of my persistence and several phone calls could claim to know her. No discussion had taken place between her and the visiting doctor. Clearly the notes were either not detailed or clear enough or not read.
I brought my mother home from hospital on Saturday Of course they found nothing untoward. She was a bit disconcerted by her trip. If it hadn't been me she would still be there this morning because the system would have required assessments and planning to be done.
Primary care is at a cross roads Much is written about its future. It is in crisis. To survive it must clearly define what is its unique contribution to health care. What can it provide that no other part of the system can. Surely that has to be personal continuity of care for those who are most vulnerable and those with multiple complex illness.
What did my mothers gp offer her on Friday that a paramedic or A&E doctor who had never met her before could not have? Nothing. She was bundled into an ambulance in her nightie with no information about her or her problems. to a ward designed to deal with emergencies with staff who knew nothing about her. It was a frightening and completely unnecessary experience for her.
It cost the NHS upwards of a thousand pounds and resulted in no improvement in her care.
If this is all general practice has to offer it will simply become an irrelevance in the system, which will eventually decide it has no value and design something else to fill the void. As a profession GPs need to sort out their own story about their future, their relevance to a changed world and deal with the unacceptable variation in standards of care that mean examples like these are quoted all too readily to denigrate the service I have spent my life developing. It brings me no joy to tell this story today.
What needed to be different?
1. Good GP notes with a clear up to date summary
2. A practice system that flags vulnerable patients ( and if my mum who at 94 has profound dementia and had had 3 unnecessary urgent admissions in the last 18 months, isn't vulnerable who is?)
3. A receptionist on the visit request desk who sees the flag and directs the call to the patients named doctor or their GP buddy if they aren't in.
4. A named GP system that actually means something real, where that person is responsible for delivering on going holistic proactive care.
5. Either the named GP is able to visit that day or if that really isn't possible briefs the visiting gp and is available to discuss with them what they find at the visit BEFORE a decision about next steps is made.
6. Have a proper emergency plan for these patients proactively discussed with relatives in place etc. This could have prevented the alast 4 hospital admission
It is not rocket science is it? Would it be more resource intensive in the long run for the practice, for the system?? Not if it is properly organised
I have worked in primary care for 25 years. I am it biggest fan. Is is all as bad as this? No. but if it doesn't collectively get its act together and sort this stuff out it will not survive.
What will I do next? well I will send the practice my blog. I could complain but am concerned all I will get will be a list of platitudes and justifications rather than a commitment to really overhaul their system. I will think about changing practices but how do I know where to find something good? It isn't as easy as a nice looking building or a fancy website.
CCGs are co-commissioning primary care. Where do we start? Accountable care organisations might be the next step. To put it bluntly If the practice had to pay for that episode of care would they have made the same choices ? I doubt it. But primary care in a million miles way from seeing this future.
In the mean time my Mum is settled back at home until the next time.....
I have written about my mum in the past. Yes, she is only one patient with her own story but so often it seems to me to reflect the bigger issues we face as we try to sort out the system and make it better.
On Friday morning my mother fell. Not a big fall but enough to worry the carers who do such a good job day to day and cope with her increasing confusion and distressing incontinence with sensitivity and kindness. They phoned her GP surgery. This is the surgery that tells you on the opening recorded message how busy they are. The same surgery where a receptionist told me a few weeks ago that the letter informing me of my mothers named GP didn't actually mean anything real and was just a "government initiative"
The duty doctor responded to the visit request. She has been in the practice less than a month. She clearly hadn't read my mothers notes: Did not know about her frequent falls, her previous admissions ( all unnecessary) her recent change in medication. more importantly she didn't have any idea about her usual level of confusion What did she do? She summoned an ambulance and sent her into hospital
My mother was no more unwell than she is every day There was no emergency. She tried to call me once, but I was in a meeting and had my phone on silent. By the time I phoned back it was too late. The NHS machine was already in motion. but why? Because she couldn't be bothered to find out more, and wait to see how the day unfolded. It was laziness justified by business. My mothers named doctor was in the practice that day. She has seen her once but because of my persistence and several phone calls could claim to know her. No discussion had taken place between her and the visiting doctor. Clearly the notes were either not detailed or clear enough or not read.
I brought my mother home from hospital on Saturday Of course they found nothing untoward. She was a bit disconcerted by her trip. If it hadn't been me she would still be there this morning because the system would have required assessments and planning to be done.
Primary care is at a cross roads Much is written about its future. It is in crisis. To survive it must clearly define what is its unique contribution to health care. What can it provide that no other part of the system can. Surely that has to be personal continuity of care for those who are most vulnerable and those with multiple complex illness.
What did my mothers gp offer her on Friday that a paramedic or A&E doctor who had never met her before could not have? Nothing. She was bundled into an ambulance in her nightie with no information about her or her problems. to a ward designed to deal with emergencies with staff who knew nothing about her. It was a frightening and completely unnecessary experience for her.
It cost the NHS upwards of a thousand pounds and resulted in no improvement in her care.
If this is all general practice has to offer it will simply become an irrelevance in the system, which will eventually decide it has no value and design something else to fill the void. As a profession GPs need to sort out their own story about their future, their relevance to a changed world and deal with the unacceptable variation in standards of care that mean examples like these are quoted all too readily to denigrate the service I have spent my life developing. It brings me no joy to tell this story today.
What needed to be different?
1. Good GP notes with a clear up to date summary
2. A practice system that flags vulnerable patients ( and if my mum who at 94 has profound dementia and had had 3 unnecessary urgent admissions in the last 18 months, isn't vulnerable who is?)
3. A receptionist on the visit request desk who sees the flag and directs the call to the patients named doctor or their GP buddy if they aren't in.
4. A named GP system that actually means something real, where that person is responsible for delivering on going holistic proactive care.
5. Either the named GP is able to visit that day or if that really isn't possible briefs the visiting gp and is available to discuss with them what they find at the visit BEFORE a decision about next steps is made.
6. Have a proper emergency plan for these patients proactively discussed with relatives in place etc. This could have prevented the alast 4 hospital admission
It is not rocket science is it? Would it be more resource intensive in the long run for the practice, for the system?? Not if it is properly organised
I have worked in primary care for 25 years. I am it biggest fan. Is is all as bad as this? No. but if it doesn't collectively get its act together and sort this stuff out it will not survive.
What will I do next? well I will send the practice my blog. I could complain but am concerned all I will get will be a list of platitudes and justifications rather than a commitment to really overhaul their system. I will think about changing practices but how do I know where to find something good? It isn't as easy as a nice looking building or a fancy website.
CCGs are co-commissioning primary care. Where do we start? Accountable care organisations might be the next step. To put it bluntly If the practice had to pay for that episode of care would they have made the same choices ? I doubt it. But primary care in a million miles way from seeing this future.
In the mean time my Mum is settled back at home until the next time.....
Monday 8 September 2014
Inside Out.....
There has been a big and very positive response to my blog about Gemma. That is great and I am glad it has made people think about the issues and talk about things. September 10th is World Suicide Prevention Day. When I came back from leave I found that my team at the CCG, fired up by my blog had decided to have an” inside out” day to highlight suicide prevention on Wednesday. This event is being organised by http://www.ifucareshare.co.uk. The idea is we all wear out clothes inside out and then wear a button that askes people to ask us why and then explain suicide prevention awareness to them… we will have a banner on our emails.
Did you know:
• 1 Million people across the globe die by suicide each year.
• Suicide is now the biggest killer of young males in this country aged 15-35 years
• The North East has the highest suicide rate in this country
• More people die by suicide each year than by murder and war combined.
WE need to talk about these things. Helping people express their feelings, sharing them with others is the first step. We need to understand suicide is the tragic end point of serious mental illness, or a moment of complete despair and isolation where no other option feels possible.
When I was young my cousin committed suicide. She had bipolar disorder. She was 27. She didn’t even have a funeral. It was shameful then. We never talked about it as a family and her parents stoically went on with their lives. To their neighbours and friends they seemed fine, they were members of Rotary and the Conservative Club. Social doers. But I knew the terrible sense of loss and sadness they carried wordlessly, unable to share even with each other, for the rest of their lives. It robbed them of any real joy in life. There were moments when the pain was visible beneath the veneer and they talked in hush voices to their daughter’s friend, me, who had loved her too.
Are we better at it now? I don’t know. It is less shameful maybe. As a health system we examine the case, we assure ourselves there was nothing more anyone could have done. No one to blame. But do we ask ourselves the bigger questions? Do we invest in services which help prevent this- which give young people the tools and the confidence to make a different choice? Do we talk openly to our children about their feelings and their fears? Do we have responsive services for those in our care with significant mental health problems so they can tell us that it is getting too desperate. We know the answers to these questions don’t we?
How many organisations out there are doing anything to mark this World Day? If we are all baking away for the Macmillan coffee morning day and dousing ourselves in icy water for MND, where is the equal publicity for this event that seeks to highlight the terrible tragedy that robs us all of increasing numbers of young and old without warning? I am glad my blog touched people but we all need to do something differently to make things different.
So what will we do? Well we will have the Inside Out Day and we will talk about it to anyone and everyone we come into contact with. We will publicise it on our website. We will work hard with our providers of mental health services to improve our services to young people especially. We will commit to developing mental health services in our area giving an increasing proportion of our budget next year as we did this year, to begin to put right the years of underfunding that went before.
Did you know:
• 1 Million people across the globe die by suicide each year.
• Suicide is now the biggest killer of young males in this country aged 15-35 years
• The North East has the highest suicide rate in this country
• More people die by suicide each year than by murder and war combined.
WE need to talk about these things. Helping people express their feelings, sharing them with others is the first step. We need to understand suicide is the tragic end point of serious mental illness, or a moment of complete despair and isolation where no other option feels possible.
When I was young my cousin committed suicide. She had bipolar disorder. She was 27. She didn’t even have a funeral. It was shameful then. We never talked about it as a family and her parents stoically went on with their lives. To their neighbours and friends they seemed fine, they were members of Rotary and the Conservative Club. Social doers. But I knew the terrible sense of loss and sadness they carried wordlessly, unable to share even with each other, for the rest of their lives. It robbed them of any real joy in life. There were moments when the pain was visible beneath the veneer and they talked in hush voices to their daughter’s friend, me, who had loved her too.
Are we better at it now? I don’t know. It is less shameful maybe. As a health system we examine the case, we assure ourselves there was nothing more anyone could have done. No one to blame. But do we ask ourselves the bigger questions? Do we invest in services which help prevent this- which give young people the tools and the confidence to make a different choice? Do we talk openly to our children about their feelings and their fears? Do we have responsive services for those in our care with significant mental health problems so they can tell us that it is getting too desperate. We know the answers to these questions don’t we?
How many organisations out there are doing anything to mark this World Day? If we are all baking away for the Macmillan coffee morning day and dousing ourselves in icy water for MND, where is the equal publicity for this event that seeks to highlight the terrible tragedy that robs us all of increasing numbers of young and old without warning? I am glad my blog touched people but we all need to do something differently to make things different.
So what will we do? Well we will have the Inside Out Day and we will talk about it to anyone and everyone we come into contact with. We will publicise it on our website. We will work hard with our providers of mental health services to improve our services to young people especially. We will commit to developing mental health services in our area giving an increasing proportion of our budget next year as we did this year, to begin to put right the years of underfunding that went before.
Friday 15 August 2014
All about Gemma
Parity of esteem. A big phrase. We are all signed up to it. But what does it really mean? I was thinking about this after hearing of Robin Williams’ death. Such a tragedy. Depression is a life threatening illness in its most severe forms. A man who seemingly has so much felt such despair that death was the only deliverance from the pain. WE don’t treat it as such and yet mental illness kills people just like cancer does.
When we talk about illness and pain we still divide our thinking into physical and mental causes. Why? The brain is physical, mental illness is about the brain and chemicals … and yet in our thinking we consider them differently. Someone with a mental health problem is still seen as somehow responsible in some way for their illness. And yet every illness has both physical and psychological components. When as a GP I talk to patients about a psychological component to their symptoms they rush to the view that I am saying it is somehow less valid ,less real, their fault. Our belief system leads us to believe mental health issues are based somehow in weakness, a flaw in our constitution and yet those with mental illness are some of the strongest and bravest people I have ever known.
We talk freely about our family members struck down by cancer but we are less willing to talk about those with depression, psychosis or substance misuse. On some level that remains private, uncomfortable.
There is a strong history of mental illness in my family. So I have watched people I love struggle to survive and witnessed how we as a society respond. Gemma was young when she developed severe depression. Her school was, it seemed, a caring and supportive place. At the same time there was another pupil who developed cancer. The contrast in the way the school handled their response to both pupils was illustrative of the deeply held values that are part of our culture. Both were very ill. Both had life threatening illnesses. Both had long periods in hospitals 50 miles away. Both missed many months of school. One had a computer bought for her, work sent to her, regular visits made to her, cards sent to her, regular updates of her progress in her form and support to her siblings and extended family. The other had nothing. This I believe was not because the school was uncaring or unkind. It just didn’t occur to those in charge. They treated these two poorly girls completely differently, one was “ill” the other “troubled”.
WE as a society raise money for cancer sufferers, run for them, swim for them, build beautiful new shiny buildings full of state of the art equipment for them, but we don’t do the same for those people with mental illness, many of whom still languish in old poorly equipped facilities. They remain on the “edge” of our health services and the “edge” of our generosity as a society. Within the NHS doctors and nurses still draw lines around mental and physical illness rather than seeing people as individuals with complex problems, we as clinicians still perpetuate the belief system that underpins the prejudice.
I read today that more ex-service men have taken their own lives than died in Afghanistan. I am not surprised. But are we outraged as a society about that? WE should be.
Parity of esteem is a grand ambition. WE can do our best as a CCG to make sure we do that. We can write it into our plans, benchmark our investments, include it in our specifications. But for things to change we must all be prepared to do everything differently. To challenge long held beliefs and social norms. Gemma’s family accepted mutely the response of the school, the neighbourhood, the extended family. We must all fight individually to expose the unconscious prejudice that is still as strong now as it was 15 years ago when Gemma was at school. What happened to Gemma? Well finally she found a psychiatrist who cared enough to discover what was important to her, who didn’t tell her as others had that she must have modest ambitions for herself because she was somehow permanently damaged by her illness. He allowed her to believe she could succeed and she has. She went to Cambridge, got 3 degrees and is deputy head of department in a large sixth form college in London after 3 years of teaching and is planning a Phd. More importantly she is well and happy. The health service is a lottery and no more so than in mental health. The struggle to find good care took 8 years.
One day I hope Gemma will write her own story. It will be heart breaking to read. For now she is getting on with her life. The scars are there though, forever in her life, made worse because the journey was so hard, the support so thin. I sent this blog to her to ask her permission to publish it, she commented “ I’ve found it much easier to come out to people about my sexuality than tell them about my depression”. That I think says it all. We, as an NHS and a society, continue to fail so many. We need to start by being honest and open about mental health, to have parity of esteem in every conversation, every interaction with staff, colleagues, friends. We need to challenge every unconsciously unkind thoughtless comment or decision. Small steps yes, but without change in the way we think as a society nothing will really change.... The NHS can lead but it cannot go it alone….
When we talk about illness and pain we still divide our thinking into physical and mental causes. Why? The brain is physical, mental illness is about the brain and chemicals … and yet in our thinking we consider them differently. Someone with a mental health problem is still seen as somehow responsible in some way for their illness. And yet every illness has both physical and psychological components. When as a GP I talk to patients about a psychological component to their symptoms they rush to the view that I am saying it is somehow less valid ,less real, their fault. Our belief system leads us to believe mental health issues are based somehow in weakness, a flaw in our constitution and yet those with mental illness are some of the strongest and bravest people I have ever known.
We talk freely about our family members struck down by cancer but we are less willing to talk about those with depression, psychosis or substance misuse. On some level that remains private, uncomfortable.
There is a strong history of mental illness in my family. So I have watched people I love struggle to survive and witnessed how we as a society respond. Gemma was young when she developed severe depression. Her school was, it seemed, a caring and supportive place. At the same time there was another pupil who developed cancer. The contrast in the way the school handled their response to both pupils was illustrative of the deeply held values that are part of our culture. Both were very ill. Both had life threatening illnesses. Both had long periods in hospitals 50 miles away. Both missed many months of school. One had a computer bought for her, work sent to her, regular visits made to her, cards sent to her, regular updates of her progress in her form and support to her siblings and extended family. The other had nothing. This I believe was not because the school was uncaring or unkind. It just didn’t occur to those in charge. They treated these two poorly girls completely differently, one was “ill” the other “troubled”.
WE as a society raise money for cancer sufferers, run for them, swim for them, build beautiful new shiny buildings full of state of the art equipment for them, but we don’t do the same for those people with mental illness, many of whom still languish in old poorly equipped facilities. They remain on the “edge” of our health services and the “edge” of our generosity as a society. Within the NHS doctors and nurses still draw lines around mental and physical illness rather than seeing people as individuals with complex problems, we as clinicians still perpetuate the belief system that underpins the prejudice.
I read today that more ex-service men have taken their own lives than died in Afghanistan. I am not surprised. But are we outraged as a society about that? WE should be.
Parity of esteem is a grand ambition. WE can do our best as a CCG to make sure we do that. We can write it into our plans, benchmark our investments, include it in our specifications. But for things to change we must all be prepared to do everything differently. To challenge long held beliefs and social norms. Gemma’s family accepted mutely the response of the school, the neighbourhood, the extended family. We must all fight individually to expose the unconscious prejudice that is still as strong now as it was 15 years ago when Gemma was at school. What happened to Gemma? Well finally she found a psychiatrist who cared enough to discover what was important to her, who didn’t tell her as others had that she must have modest ambitions for herself because she was somehow permanently damaged by her illness. He allowed her to believe she could succeed and she has. She went to Cambridge, got 3 degrees and is deputy head of department in a large sixth form college in London after 3 years of teaching and is planning a Phd. More importantly she is well and happy. The health service is a lottery and no more so than in mental health. The struggle to find good care took 8 years.
One day I hope Gemma will write her own story. It will be heart breaking to read. For now she is getting on with her life. The scars are there though, forever in her life, made worse because the journey was so hard, the support so thin. I sent this blog to her to ask her permission to publish it, she commented “ I’ve found it much easier to come out to people about my sexuality than tell them about my depression”. That I think says it all. We, as an NHS and a society, continue to fail so many. We need to start by being honest and open about mental health, to have parity of esteem in every conversation, every interaction with staff, colleagues, friends. We need to challenge every unconsciously unkind thoughtless comment or decision. Small steps yes, but without change in the way we think as a society nothing will really change.... The NHS can lead but it cannot go it alone….
Tuesday 12 August 2014
Conflicts and confusion....
All CCGs are considering co-commissioning primary care and some are keen to do it all.. budgets and all… We are more cautious. Co commissioning has 2 major flaws it seems to me, conflicts and capacity. We are living the issues that will inevitably arise when people start to do these things in earnest. We are re-procuring our community and out of hours services through a competitive dialogue. We want something new, innovative, joined up. Something that will bring together services and reduce duplication and waste. Our GP federation is probably going to bid. All the practices bar one single hander are in our federation therefore every GP on the governing body is conflicted.
Not everyone gets the problem. Many of my GP colleagues who manage confidentiality and potential conflicts of loyalty, information, role every day think it should be easy to sort and what is the fuss all about? But these issues are important.
We are a very open organisation we don’t really do secrets and huddles. From now on we will have to be careful who is in what conversation, who overhears what, what conversations are okay at lunch. WE eat lunch together each day.. or at least anyone who is in the building congregates in the kitchen. It is fun, social. We learn about each other as people with lives, families, interests. The chat is about all sorts but sometimes strays back to work. WE will just need to be careful we don’t talk about “some things” within the earshot of our GPs. It is important we can’t compromise them. Our weekly Strategic Management Team meeting is now divided into 2 with separate notes and minutes. The big stuff- Governing Body meetings etc. are easy enough it is the day to day that presents the challenge. AS we assess the PQQs we can’t use our usual clinical resource so will bus some GPS in who have very kindly agreed to help, from the north…This is a single project… when we commission primary care as a CCG which no doubt in the fullness of time we will all be doing it will be harder still.
Yet it is important. The public are rightly concerned about GPs making decisions about their own work and pay. Practices are concerned about in- crowds and outsiders…Everyone is concerned about fairness. Yes, CCGS understand primary care the best probably but are they best placed to make tough decisions about the services that are delivered by their friends and colleagues?
The second issue is do we have the skills and the time to do this well?...IT is a massive job. WE are doing good things but I worry that there comes a tipping point where if you take on too much you stop being able to be creative, productive and proactive and simply do nothing but fight the fires that have ignited when you were too busy to notice. And you end up running from one fire to another- exhausted, directionless. I have been there before.
Is this the right direction for primary care commissioning? I think the issues the services faces are huge and very complex. I am normally fairly good at coming up with solutions to problems…. But I struggle to even begin to find a model that will develop and invigorate primary care whilst safeguarding the pivotal role it delivers in the NHS within the structures we have today. National contracts, privately own premises, independent contractor status, financial pressures, scary workforce predictions around both recruitment and retirement, lack of leadership capability… all these conspire together to create an impending catastrophe for primary care and yet we are all sitting around watching feeling powerless to change things. Will co-commissioning be the answer? Definitely not in my view… but what will be?
Not everyone gets the problem. Many of my GP colleagues who manage confidentiality and potential conflicts of loyalty, information, role every day think it should be easy to sort and what is the fuss all about? But these issues are important.
We are a very open organisation we don’t really do secrets and huddles. From now on we will have to be careful who is in what conversation, who overhears what, what conversations are okay at lunch. WE eat lunch together each day.. or at least anyone who is in the building congregates in the kitchen. It is fun, social. We learn about each other as people with lives, families, interests. The chat is about all sorts but sometimes strays back to work. WE will just need to be careful we don’t talk about “some things” within the earshot of our GPs. It is important we can’t compromise them. Our weekly Strategic Management Team meeting is now divided into 2 with separate notes and minutes. The big stuff- Governing Body meetings etc. are easy enough it is the day to day that presents the challenge. AS we assess the PQQs we can’t use our usual clinical resource so will bus some GPS in who have very kindly agreed to help, from the north…This is a single project… when we commission primary care as a CCG which no doubt in the fullness of time we will all be doing it will be harder still.
Yet it is important. The public are rightly concerned about GPs making decisions about their own work and pay. Practices are concerned about in- crowds and outsiders…Everyone is concerned about fairness. Yes, CCGS understand primary care the best probably but are they best placed to make tough decisions about the services that are delivered by their friends and colleagues?
The second issue is do we have the skills and the time to do this well?...IT is a massive job. WE are doing good things but I worry that there comes a tipping point where if you take on too much you stop being able to be creative, productive and proactive and simply do nothing but fight the fires that have ignited when you were too busy to notice. And you end up running from one fire to another- exhausted, directionless. I have been there before.
Is this the right direction for primary care commissioning? I think the issues the services faces are huge and very complex. I am normally fairly good at coming up with solutions to problems…. But I struggle to even begin to find a model that will develop and invigorate primary care whilst safeguarding the pivotal role it delivers in the NHS within the structures we have today. National contracts, privately own premises, independent contractor status, financial pressures, scary workforce predictions around both recruitment and retirement, lack of leadership capability… all these conspire together to create an impending catastrophe for primary care and yet we are all sitting around watching feeling powerless to change things. Will co-commissioning be the answer? Definitely not in my view… but what will be?
Thursday 17 July 2014
Everyone is talking about change in primary care....
Our GPs came first nationally for overall patient satisfaction this week in the most recent national survey. That is a fantastic achievement. 93% of patients rated the service as good. Does that mean that things are easy in general practice here? No. Talking to the practices I know they are working really hard and struggling to meet the demand they face. They need though to be congratulated for the effort they put in to maintain such good services despite the pressures. It is an even greater achievement at a time of such pressure in the system.
General practice is under pressure as never before. A perfect storm seems imminent. The age profile of GPs in our area (and reflected nationally) points to a mass exodus over the next 5 years, exacerbated by pension changes, revalidation demands and general change and workload fatigue. At the same time applications for vocational training are at an all-time low. Our local VTS which normally has no problems recruiting has less than 25% of its usual numbers this year. They can survive one year like that but another year would mean serious problems for the area and the hospitals the training posts support. Practices are struggling to recruit. I am reliably informed the average age for a female GP to leave the services is 36! Mainly because they leave to have children and then don’t return, choosing other specialities over general practice. WE have to do something urgently to make general practice a more attractive place to work. At the same time demand is spirally upwards.
We will also have a real deficit in GP leadership. CCGs are predicated on clinical leadership from the GP community but we also now need leaders to develop and change general practice as a provider of health care, leading federations of primary care, looking to new models that both secure what is best about primary care whilst responding to the challenges of a changing work force and service demand.
And there really is some urgency about finding solutions. Poor primary care will lead inevitably to increased demand on hospital services.
I have been out of clinical practice for just over a year. I returned recently to my old practice for a meeting. AS I walked across the threshold I was struck by the return of what I can only describe as “ a tension in my gut” and I recognised that feeling as something was there every day at work but had never consciously felt it. I only was able to recognise it in retrospect. Looking back I can see it was all about managing the unpredictability of the day and making decisions big and small.. all day.. managing risk… all day every day… I did it for 25 years and loved it but it is a tough job. And it is getting tougher. The role of the gatekeeper to the service is underplayed but it is a vital part of our system.
As a profession though, we must resist the impulse to push patients away as a response to overwork and the pressure. I phoned my Mums GP practice this week and asked for someone to visit her. No panic. Not urgent but she is too confused now to visit the practice. It would be too frightening for her. We had received a letter telling us who her “named GP” was. I was relieved. At 94 and having been at the practice for 10 years she is still only ever seen in one off episodes. When I requested that the named GP visit her… I was told promptly that the service “doesn’t work like that” and anyway “it was just a government paper exercise”. If we are going to campaign about poor funding and workload pressure surely GPs must still occupy the moral high ground and do our best for our most vulnerable patients. We must remain the advocate for patients . When I told my story many people responded they too had found themselves “fighting” to get in through the primary care front door. This wasn’t good enough for me, for my Mum. I made a fuss and in the end she was visited but it shouldn’t be because of who I am. It should be there as a right for everyone.
What can CCGs do? Well we have commissioning an “out of hospital scheme” this year… rolling up our local enhanced services monies and adding some more to move services AND the funding out of hospital and into practices. We supported our GPs to successfully bid for the Prime Ministers Challenge fund, and we are working with our local VTS to develop services in our local DGH that will make coming to our area as a trainee more attractive, and develop roles for trainees within the CCG. WE are also doing our best to develop and support any GPs who demonstrate interest in leadership, by offering bespoke roles and leadership skills training. We have expressed an interest in gently becoming involved in co-commissioning but we anticipate the issues will be complex and are concerned about a general lack of capacity either within area teams or at CCG level. It is a complex agenda and needs good people to invest time and energy into getting it right.
It isn’t enough. Some of the solutions need national action…the first step is for everyone to acknowledge the size of the issue we face and to understand what is driving people away from primary care and into other career choices. Of course waning interest in primary care as a career has happened before and the profession has survived but the issues around retirement weren’t there then, GPs were staying on into their 60s.. they aren’t now so unless we address the issues we will fall down a hole and such high levels of user satisfaction in primary care everywhere, but particularly in our area will be a fading memory….
General practice is under pressure as never before. A perfect storm seems imminent. The age profile of GPs in our area (and reflected nationally) points to a mass exodus over the next 5 years, exacerbated by pension changes, revalidation demands and general change and workload fatigue. At the same time applications for vocational training are at an all-time low. Our local VTS which normally has no problems recruiting has less than 25% of its usual numbers this year. They can survive one year like that but another year would mean serious problems for the area and the hospitals the training posts support. Practices are struggling to recruit. I am reliably informed the average age for a female GP to leave the services is 36! Mainly because they leave to have children and then don’t return, choosing other specialities over general practice. WE have to do something urgently to make general practice a more attractive place to work. At the same time demand is spirally upwards.
We will also have a real deficit in GP leadership. CCGs are predicated on clinical leadership from the GP community but we also now need leaders to develop and change general practice as a provider of health care, leading federations of primary care, looking to new models that both secure what is best about primary care whilst responding to the challenges of a changing work force and service demand.
And there really is some urgency about finding solutions. Poor primary care will lead inevitably to increased demand on hospital services.
I have been out of clinical practice for just over a year. I returned recently to my old practice for a meeting. AS I walked across the threshold I was struck by the return of what I can only describe as “ a tension in my gut” and I recognised that feeling as something was there every day at work but had never consciously felt it. I only was able to recognise it in retrospect. Looking back I can see it was all about managing the unpredictability of the day and making decisions big and small.. all day.. managing risk… all day every day… I did it for 25 years and loved it but it is a tough job. And it is getting tougher. The role of the gatekeeper to the service is underplayed but it is a vital part of our system.
As a profession though, we must resist the impulse to push patients away as a response to overwork and the pressure. I phoned my Mums GP practice this week and asked for someone to visit her. No panic. Not urgent but she is too confused now to visit the practice. It would be too frightening for her. We had received a letter telling us who her “named GP” was. I was relieved. At 94 and having been at the practice for 10 years she is still only ever seen in one off episodes. When I requested that the named GP visit her… I was told promptly that the service “doesn’t work like that” and anyway “it was just a government paper exercise”. If we are going to campaign about poor funding and workload pressure surely GPs must still occupy the moral high ground and do our best for our most vulnerable patients. We must remain the advocate for patients . When I told my story many people responded they too had found themselves “fighting” to get in through the primary care front door. This wasn’t good enough for me, for my Mum. I made a fuss and in the end she was visited but it shouldn’t be because of who I am. It should be there as a right for everyone.
What can CCGs do? Well we have commissioning an “out of hospital scheme” this year… rolling up our local enhanced services monies and adding some more to move services AND the funding out of hospital and into practices. We supported our GPs to successfully bid for the Prime Ministers Challenge fund, and we are working with our local VTS to develop services in our local DGH that will make coming to our area as a trainee more attractive, and develop roles for trainees within the CCG. WE are also doing our best to develop and support any GPs who demonstrate interest in leadership, by offering bespoke roles and leadership skills training. We have expressed an interest in gently becoming involved in co-commissioning but we anticipate the issues will be complex and are concerned about a general lack of capacity either within area teams or at CCG level. It is a complex agenda and needs good people to invest time and energy into getting it right.
It isn’t enough. Some of the solutions need national action…the first step is for everyone to acknowledge the size of the issue we face and to understand what is driving people away from primary care and into other career choices. Of course waning interest in primary care as a career has happened before and the profession has survived but the issues around retirement weren’t there then, GPs were staying on into their 60s.. they aren’t now so unless we address the issues we will fall down a hole and such high levels of user satisfaction in primary care everywhere, but particularly in our area will be a fading memory….
Tuesday 8 July 2014
Hard work should be fun!
It is a while since I have written my blog…. I guess life got in the way.. two of my daughter had babies so I have been juggling work with grandparent fun stuff and some things have to slip… anyway.. as I have driven round the country I had had many potential blogs running around my brain..
Every day as I listen to Radio 4 Today programme on my way to work I hear the endless drip of negative NHS stories, we seem as a nation intent on always believing the worst. It makes me sad. For those of us working in the service working really hard to make it better but believing we already deliver a service that is good for most, excellent for some but we know it is poor for some too .. and no room for complacency and so many challenges ahead. But all the negative makes it hard to feel good about what we do every day when we come to work. It weighs you down. My daughters had a patchwork of experiences.. some good.. some excellent some only average.. mostly dependant on the individuals they came across. So much of what influences patient experience is the attitude of the individuals who deliver the service..and what mattered to them was being involved in decisions, treated like a person not a walking womb, given time, looked at and acknowledged. Simple stuff. But that simple stuff happens when the organisation allows individuals who work there to flourish and enjoy their work. To feel valued and important. When you feel valued it is easy to help others to feel like that too. It is infectious!
At a time of such threat and challenge in the system it is more important than it ever has been that those who work in the NHS feels valued and can feel good about coming to work. WE talk about fun. Is it fun to be at work? If I hear laughter in my organisation I feel we are on track. Yes we are busy and we do a lot every day.. but we can also be relaxed enough with each other to laugh at lunch times, which we have together in the kitchen and even at the meetings where important work is done too.
We have developed a game to play with our stakeholders and the public called “Strictly Come Commissioning”. It is a board game played by a group of people playing at being commissioners for a day We piloted it our recent Health Watch conference and it went really well. It stimulated lots of conversation and debate about all sorts of issues. There was a real buzz in the room. Should we commission services for people who smoke/are overweight/ subfertile? How do those services stack up against services for people with cancer or autism? What do you do when urgent admissions spiral out of control? We did get a letter for someone who got the invite but didn’t attend saying we shouldn’t be playing a game about serious things.. but we learn through play and it was fun. Is that wrong? When did work become something that had to be serious all the time? Surely that isn’t a natural way to be? We are now thinking we could use the game to explain commissioning to all sorts of groups: GP trainee doctors, A level students, patient groups, surely better than me standing there with a powerpoint?
So whilst we are all working so hard changing so much, working under such pressure, lets remember also to have moments of lightness and fun too. It helps teams to value each other and work better together and it doesn’t reflect any lack of commitment to the job. I read somewhere that adults laugh an average of 9 times a day compared to children who laugh 40-50 times a day. So here’s to hard work and laughter.
Every day as I listen to Radio 4 Today programme on my way to work I hear the endless drip of negative NHS stories, we seem as a nation intent on always believing the worst. It makes me sad. For those of us working in the service working really hard to make it better but believing we already deliver a service that is good for most, excellent for some but we know it is poor for some too .. and no room for complacency and so many challenges ahead. But all the negative makes it hard to feel good about what we do every day when we come to work. It weighs you down. My daughters had a patchwork of experiences.. some good.. some excellent some only average.. mostly dependant on the individuals they came across. So much of what influences patient experience is the attitude of the individuals who deliver the service..and what mattered to them was being involved in decisions, treated like a person not a walking womb, given time, looked at and acknowledged. Simple stuff. But that simple stuff happens when the organisation allows individuals who work there to flourish and enjoy their work. To feel valued and important. When you feel valued it is easy to help others to feel like that too. It is infectious!
At a time of such threat and challenge in the system it is more important than it ever has been that those who work in the NHS feels valued and can feel good about coming to work. WE talk about fun. Is it fun to be at work? If I hear laughter in my organisation I feel we are on track. Yes we are busy and we do a lot every day.. but we can also be relaxed enough with each other to laugh at lunch times, which we have together in the kitchen and even at the meetings where important work is done too.
We have developed a game to play with our stakeholders and the public called “Strictly Come Commissioning”. It is a board game played by a group of people playing at being commissioners for a day We piloted it our recent Health Watch conference and it went really well. It stimulated lots of conversation and debate about all sorts of issues. There was a real buzz in the room. Should we commission services for people who smoke/are overweight/ subfertile? How do those services stack up against services for people with cancer or autism? What do you do when urgent admissions spiral out of control? We did get a letter for someone who got the invite but didn’t attend saying we shouldn’t be playing a game about serious things.. but we learn through play and it was fun. Is that wrong? When did work become something that had to be serious all the time? Surely that isn’t a natural way to be? We are now thinking we could use the game to explain commissioning to all sorts of groups: GP trainee doctors, A level students, patient groups, surely better than me standing there with a powerpoint?
So whilst we are all working so hard changing so much, working under such pressure, lets remember also to have moments of lightness and fun too. It helps teams to value each other and work better together and it doesn’t reflect any lack of commitment to the job. I read somewhere that adults laugh an average of 9 times a day compared to children who laugh 40-50 times a day. So here’s to hard work and laughter.
Tuesday 29 April 2014
More Good news!
I think I am on a roll about good news. Since writing my previous blog I have had many conversations with people who are fed up with all the gloom. So today I am also writing about good things happening in the NHS.
I will start with an update about my Mum. Those of you who have read my blog in the past will know about my Mum and the problems she faced last year. She is 94 next week and has escalating problems with dementia. Last year she had the classic story of a series of falls, increasing anxiety and 3 unnecessary urgent admissions at a hospital because there was nowhere else for her to go and in the end was placed in a nursing home as a place of safety because being home was no longer manageable. Having visits for 21 different carers a week and then probably 15 other people popping in with meals, medication, monitoring her falls risks and her mental state etc etc was just too much for someone already confused and frightened by her confusion. It could so easily have ended there… but we were lucky. She lives in an area where there is “extra care”. Having read Roy Lilleys’s blog I now realise this isn’t universal so we as a family have been lucky.
We as a CCG are also lucky that our local authority are developing extra care at pace across the county.
So what is extra care?.. ... My Mum still has her own flat, her own front door. She is still home. A team of carers work in the building and Mum has got to know them and to trust them. Although that did take time. At first she wouldn’t shower or wash, but then why should it be easier for her to get naked with a stranger just because she is old? She showers now. At first she was rude and difficult with the carers lecturing them about their educational achievements and that they should try harder. She was a teacher. It was excruciating to witness but the carers managed her with kindness and tolerance and gradually as it all became more familiar she became calmer. She has meals with all the other residents at midday and her other meals prepared by the carers in her flat. A team of people do her shopping, washing and cleaning. When she falls ,night or day she calls them and they are there on the premises, they assess her and then pop her back in her chair or into bed. No 999, no A&E. AS long as her behaviour remains manageable she should be able to stay there as her memory shrinks further. She is content. Her aggression is very much linked to anxiety so hopefully now everything is familiar it won’t be a problems although of course you never know. Many extra care facilities keep people even when they are very demented. Technology allows monitoring of wandering , falling etc. My Mum is also no longer lonely. The carers and other residents have become part of her world rather than strangers and although she doesn’t talk to them much they give her a sense of community and belonging.
I was at a public meeting locally when someone in the audience said they would hate to live in a place like that “ a rabbit hutch for old people” and yes I can see why when you look in from the outside it might seem like that but what I have learned from watching my Mum is that her needs and aspirations have changed as she has aged and whatever I may think about it ,she is content and that is what matters.
As a CCG we are working with our Local Authority to develop integrated health and extra care models to jointly commission facilities where frail older people can be supported to be independent but access the care and the companionship they need. Maybe a community hospital co-located with an extra care building with shared staff and more importantly shared ethos. We could also add housing for younger people living with serious chronic illness or disability, who need nursing and care support but are keen to live independently. These new developments will take time and will need our public to be along side us. For now we are working with the local authority to get the best out the ones already built so that we maximise joined up input to keep residents as healthy as they can be for a long as possible .
This morning I was discussing with one of our local physicians from our local acute trust the recent experience of his pilot in our local A&E where he and a colleague work two shifts a week to trial consultant assessment at the front of house. Yesterday evening he saw 8 patients, sent 6 home with the much improved community and social care support that we have been developing over the last year including night caring, integrated neighbourhood health and social care teams, better resourced social care assessment and fast response etc. One of the two who were admitted clearly could have been managed at home with the right more enhanced home care so we will work to provide that. So that is 6 patients who would have found their way into an acute bed able to go home and have their treatment and care there. Last year our urgent admissions reduced by 3%. He is convinced that because we have good primary and community care we can manage more of the people at present on his wards at home. With investments we are making this year we can do it better and for more people. We just need the collective will and the confidence to do it. We are developing a “hot clinic” in our community hospital run by physicians, therapists, social care and community nursing to urgently address the needs of older people who are becoming frail before they hit a crisis.
It is all good stuff. Is it big enough? Well, you could look at each initiative and accuse CCGs of playing at the edges, not being strategic or ambitious enough. Or you could see each scheme as part of a much bigger picture and acknowledge that CCGs are making changes on the ground; changes that mean better services for individual patients and their families; changes led by local doctors, nurses ,social workers and therapists; changes that are there to address the difficult issues no one in the past has had the will to sort out, changes that will add up to a better system, a system that is better than the sum of its parts.
I will start with an update about my Mum. Those of you who have read my blog in the past will know about my Mum and the problems she faced last year. She is 94 next week and has escalating problems with dementia. Last year she had the classic story of a series of falls, increasing anxiety and 3 unnecessary urgent admissions at a hospital because there was nowhere else for her to go and in the end was placed in a nursing home as a place of safety because being home was no longer manageable. Having visits for 21 different carers a week and then probably 15 other people popping in with meals, medication, monitoring her falls risks and her mental state etc etc was just too much for someone already confused and frightened by her confusion. It could so easily have ended there… but we were lucky. She lives in an area where there is “extra care”. Having read Roy Lilleys’s blog I now realise this isn’t universal so we as a family have been lucky.
We as a CCG are also lucky that our local authority are developing extra care at pace across the county.
So what is extra care?.. ... My Mum still has her own flat, her own front door. She is still home. A team of carers work in the building and Mum has got to know them and to trust them. Although that did take time. At first she wouldn’t shower or wash, but then why should it be easier for her to get naked with a stranger just because she is old? She showers now. At first she was rude and difficult with the carers lecturing them about their educational achievements and that they should try harder. She was a teacher. It was excruciating to witness but the carers managed her with kindness and tolerance and gradually as it all became more familiar she became calmer. She has meals with all the other residents at midday and her other meals prepared by the carers in her flat. A team of people do her shopping, washing and cleaning. When she falls ,night or day she calls them and they are there on the premises, they assess her and then pop her back in her chair or into bed. No 999, no A&E. AS long as her behaviour remains manageable she should be able to stay there as her memory shrinks further. She is content. Her aggression is very much linked to anxiety so hopefully now everything is familiar it won’t be a problems although of course you never know. Many extra care facilities keep people even when they are very demented. Technology allows monitoring of wandering , falling etc. My Mum is also no longer lonely. The carers and other residents have become part of her world rather than strangers and although she doesn’t talk to them much they give her a sense of community and belonging.
I was at a public meeting locally when someone in the audience said they would hate to live in a place like that “ a rabbit hutch for old people” and yes I can see why when you look in from the outside it might seem like that but what I have learned from watching my Mum is that her needs and aspirations have changed as she has aged and whatever I may think about it ,she is content and that is what matters.
As a CCG we are working with our Local Authority to develop integrated health and extra care models to jointly commission facilities where frail older people can be supported to be independent but access the care and the companionship they need. Maybe a community hospital co-located with an extra care building with shared staff and more importantly shared ethos. We could also add housing for younger people living with serious chronic illness or disability, who need nursing and care support but are keen to live independently. These new developments will take time and will need our public to be along side us. For now we are working with the local authority to get the best out the ones already built so that we maximise joined up input to keep residents as healthy as they can be for a long as possible .
This morning I was discussing with one of our local physicians from our local acute trust the recent experience of his pilot in our local A&E where he and a colleague work two shifts a week to trial consultant assessment at the front of house. Yesterday evening he saw 8 patients, sent 6 home with the much improved community and social care support that we have been developing over the last year including night caring, integrated neighbourhood health and social care teams, better resourced social care assessment and fast response etc. One of the two who were admitted clearly could have been managed at home with the right more enhanced home care so we will work to provide that. So that is 6 patients who would have found their way into an acute bed able to go home and have their treatment and care there. Last year our urgent admissions reduced by 3%. He is convinced that because we have good primary and community care we can manage more of the people at present on his wards at home. With investments we are making this year we can do it better and for more people. We just need the collective will and the confidence to do it. We are developing a “hot clinic” in our community hospital run by physicians, therapists, social care and community nursing to urgently address the needs of older people who are becoming frail before they hit a crisis.
It is all good stuff. Is it big enough? Well, you could look at each initiative and accuse CCGs of playing at the edges, not being strategic or ambitious enough. Or you could see each scheme as part of a much bigger picture and acknowledge that CCGs are making changes on the ground; changes that mean better services for individual patients and their families; changes led by local doctors, nurses ,social workers and therapists; changes that are there to address the difficult issues no one in the past has had the will to sort out, changes that will add up to a better system, a system that is better than the sum of its parts.
Thursday 17 April 2014
Getting better?
We read a lot about how bad things are in the NHS… how tough life is for staff how terrible for patients… but it is never universally true..and there are good news stories too. WE don’t often hear them because somehow they aren’t as news worthy… it is sad to me that a good news story comes and goes , little is said about it whilst bad news is the stuff we discuss in coffee shops across the land…..what does it say about us all that we would rather dissect all the bad things that happen rather than celebrate the good.?
Our GPs were successful in getting the challenge fund bid. An injection of cash which allows them to really work on how to improve primary care into the future and the time and space to do it right: A rare opportunity, a fantastic thing. It was covered my our local paper on the front page but we hardly received a call from the media who are normally all over us when something is difficult or contentious. One of my colleagues said to me yesterday they were surprised by the lack of interest. Many members of the public stop me in the street and ask me why they don’t heard more about the good things we are doing. Well we try, but putting out press releases it not the same thing as getting things into the press!
We have lots of good news! As a health economy we have balanced our books for the first time in many many years.. having paid back debt inherited from our PCT. We are investing in community services to build a robust and coordinated community system, mental health services especially services for people with dementia. We are putting back things our PCT had stripped out in an ever increasingly desperate attempt to balance.. like IVF. .investment in weight management services, autism services, counselling services etc..etc… Staff who came with us from the PCT are excited and energised because we are actually getting to do the right things..rather than endlessly talking about taking reducing services… we are building our communities, strengthening local services, working in collaboration with our GPs to make things better, brining care closer to home. We have wrapped up our local enhanced service monies into one basket scheme and added some to it, so it is now an “out of hospital scheme” and includes the monitoring of stable prostate cancer patients, acute catheterisation, taking patients from the ambulance service who called 999 but are assessed as being suitable for GP services, DVT assessment et etc and is now delivered by all our practices to all our patients. Fantastic.. and we will add more.. .we are now looking at preoperative assessment etc. It is actually taking care out of distant hospitals and bringing it home. It is a small but important change and by doing it for every patient we can actually decommission the service from the acute hospital. It is one small example of something good. Many have written that CCGS haven’t delivered. My response is give us a chance! We have only been here for a year. Show me the PCT that made significant change in a year! And we all know that transformational change is actually a series of small changes that build a new system.. a pointillist painting…
It almost feels now that saying positive things isnt allowed... we are all supposed just to say how difficult and awful everything is. I remember years ahgo I went to a conference where a "motivational speaker" was first on the agenda. AS we waited for her my heart sank..this is going to be a waste of time/embarrasing etc but it was amazing. She challenged us all about our positivity.She asked us to stand up and tell the audience something great we had done over the previous weekend. We all loooked to the floor avoiding eye contact. She then posed the question " why do children go into school on Mondays bursting to tell the class about the wonderful things they did at the weekend whilst when I asked you you all stared at the floor? When does that happen?
WE have fun at work. WE laugh. We DO. We are proud of what we are doing. IT feels good.
We know there are clouds looming. WE aren’t immune from the threats we all face but can we please please sometimes celebrate the good?
Our GPs were successful in getting the challenge fund bid. An injection of cash which allows them to really work on how to improve primary care into the future and the time and space to do it right: A rare opportunity, a fantastic thing. It was covered my our local paper on the front page but we hardly received a call from the media who are normally all over us when something is difficult or contentious. One of my colleagues said to me yesterday they were surprised by the lack of interest. Many members of the public stop me in the street and ask me why they don’t heard more about the good things we are doing. Well we try, but putting out press releases it not the same thing as getting things into the press!
We have lots of good news! As a health economy we have balanced our books for the first time in many many years.. having paid back debt inherited from our PCT. We are investing in community services to build a robust and coordinated community system, mental health services especially services for people with dementia. We are putting back things our PCT had stripped out in an ever increasingly desperate attempt to balance.. like IVF. .investment in weight management services, autism services, counselling services etc..etc… Staff who came with us from the PCT are excited and energised because we are actually getting to do the right things..rather than endlessly talking about taking reducing services… we are building our communities, strengthening local services, working in collaboration with our GPs to make things better, brining care closer to home. We have wrapped up our local enhanced service monies into one basket scheme and added some to it, so it is now an “out of hospital scheme” and includes the monitoring of stable prostate cancer patients, acute catheterisation, taking patients from the ambulance service who called 999 but are assessed as being suitable for GP services, DVT assessment et etc and is now delivered by all our practices to all our patients. Fantastic.. and we will add more.. .we are now looking at preoperative assessment etc. It is actually taking care out of distant hospitals and bringing it home. It is a small but important change and by doing it for every patient we can actually decommission the service from the acute hospital. It is one small example of something good. Many have written that CCGS haven’t delivered. My response is give us a chance! We have only been here for a year. Show me the PCT that made significant change in a year! And we all know that transformational change is actually a series of small changes that build a new system.. a pointillist painting…
It almost feels now that saying positive things isnt allowed... we are all supposed just to say how difficult and awful everything is. I remember years ahgo I went to a conference where a "motivational speaker" was first on the agenda. AS we waited for her my heart sank..this is going to be a waste of time/embarrasing etc but it was amazing. She challenged us all about our positivity.She asked us to stand up and tell the audience something great we had done over the previous weekend. We all loooked to the floor avoiding eye contact. She then posed the question " why do children go into school on Mondays bursting to tell the class about the wonderful things they did at the weekend whilst when I asked you you all stared at the floor? When does that happen?
WE have fun at work. WE laugh. We DO. We are proud of what we are doing. IT feels good.
We know there are clouds looming. WE aren’t immune from the threats we all face but can we please please sometimes celebrate the good?
Tuesday 25 February 2014
Challenging Times
I am slightly surprised to be writing this but The Prime Ministers Challenge Fund has done much to stimulate debate in primary care. WE have seen real enthusiasm to change things. To really get stuck into tackling the intransigent issues that face very rural health care. And this is new. WE have great GPs in our CCG, apparently they score the highest in patient satisfaction in primary care of all CCGs in the country. But they haven’t been at the forefront of innovation. What they have been great at is high quality patient centred traditional general practice that values relationship, continuity, commitment. They are mainly although not exclusively small practices dotted amongst the rolling dales and moors of North Yorkshire.
They are worried about the future, for their own services and for the wider health community. The big change is that now our GPs have said they need to stop complaining and start doing. They are planning bigger that just working together as GP practices, they want to look to providing locally based community services and out of hours services, that work closely with mental health and social care services . All joined up and working together. They are prepared to lead that. That includes looking at a different model for the GP contract too. They have a vision, they are developing how to express it and what to call it.
Most of our practices are MPIG practices and stand to lose a lot of investment over the next few years. The cynics may say that that is why they want to do this but I see it as part of a much bigger picture. It may have made them think differently but the prize of working in a system that delivers local care for local people all joined up, supporting each other reducing duplication, stopping endless journeys to distant hospitals for things that could be delivered locally and developing robust health care hubs ( or whatever you want to call them.. there are many names being banded about) would be an exciting and different place to work. Who wouldn’t want to be part of something amazing like that? Was it the fund alone? Or was it a kind of “perfect storm”? I am not sure.. what I do know is that sometimes that is just how stuff changes. Suddenly and for no apparent reason a lot of different things conspire to bring about significant shifts in attitude, in ambition.
We mustn’t lose this. If it is happening all over the country the NHS needs to find a way to harness all this energy and use it. Thee is £50M for ? 9 pilots. If there is £50M would 25 projects with £2M be another way? 2 million is a lot of money.. our CCG management budget to deliver everything is somewhere around £3.5M, do so few pilots really need so much money? I would hate to lose all this and return to the status quo…..
They are worried about the future, for their own services and for the wider health community. The big change is that now our GPs have said they need to stop complaining and start doing. They are planning bigger that just working together as GP practices, they want to look to providing locally based community services and out of hours services, that work closely with mental health and social care services . All joined up and working together. They are prepared to lead that. That includes looking at a different model for the GP contract too. They have a vision, they are developing how to express it and what to call it.
Most of our practices are MPIG practices and stand to lose a lot of investment over the next few years. The cynics may say that that is why they want to do this but I see it as part of a much bigger picture. It may have made them think differently but the prize of working in a system that delivers local care for local people all joined up, supporting each other reducing duplication, stopping endless journeys to distant hospitals for things that could be delivered locally and developing robust health care hubs ( or whatever you want to call them.. there are many names being banded about) would be an exciting and different place to work. Who wouldn’t want to be part of something amazing like that? Was it the fund alone? Or was it a kind of “perfect storm”? I am not sure.. what I do know is that sometimes that is just how stuff changes. Suddenly and for no apparent reason a lot of different things conspire to bring about significant shifts in attitude, in ambition.
We mustn’t lose this. If it is happening all over the country the NHS needs to find a way to harness all this energy and use it. Thee is £50M for ? 9 pilots. If there is £50M would 25 projects with £2M be another way? 2 million is a lot of money.. our CCG management budget to deliver everything is somewhere around £3.5M, do so few pilots really need so much money? I would hate to lose all this and return to the status quo…..
Thursday 20 February 2014
Decisions...decisions...
Two weeks ago the Council of Members of the CCG came together to make decisions about the Maternity and Childrens services at our local hospital. WE have been considering change for the last two and a half years and talking to the public about the possibilities, culminating in a public consultation which closed at the end of November. I have written about the issues on my blog before. A small hospital, mall numbers of children need admitting to hospital and no middle grade paediatric cover. A maternity unit with 1200 deliveries a year which also struggles to maintain middle grade staff and increasing concerns about safety, quality and sustainability. This was a clinically led issue.: raised by the doctors and nurses who have led this service for the last 25 years who are worried it won’t be safe into the future.
The GPs wanted to make this decision. Many smaller decisions are made by the governing body working with delegated responsibility from the GPS. However this issue felt too important and the GPs wanted to make it themselves as a group. We wanted to develop an open and transparent way to make these decisions, knowing they would be contentious and difficult., wanting to assure the public that the decisions were made thoughtfully and carefully.
As a starter the Governing Body of the CCG developed a priority framework, which was agreed and adopted by the GPs where each option was rated by every practice team in the CCG on a series of aspects: clinical effectiveness, patient experience, cost effectiveness, safety, access, sustainability and affordability. The practices used all the information we had brought together including a review of the evidence, models used around the country and internationally, economic and equality impact assessments impact of travelling , NCAT assessment and most importantly feedback from the patients and public. The practices then came together with one representative from each practice, each with delegated responsibility to speak for their practice at the meeting and feedback collectively the outcomes of the practice discussions. This was then used to develop both the shortlist for consultation and more recently to decide the outcomes of the consultation.. So for the first time the decision was made by all practices in the CCG working together. It was time consuming for us, and for the practices and could only practically be used for BIG decisions but it felt good to have such a robust method of collective decision making.
And some interesting discussions: was each practice voting on what it thought would be best for its own population or for the populations of the CCG as a whole? One of our three localities is largely unaffected by these changes but still has a role as a commissioner of service, so our job is not simply to reflect the issues for our patients in our practices but to have a wider view for all patients across our CCG. What if the discussion develops and new arguments change the overall views of the group?. Does delegated responsibility mean the rep can change their decision based on what they think their practice would do if it was sitting round the table? We agreed they could. Interestingly that was really only as issue when it came to discussing investments around supporting the changes ,not about the need for change itself.
Was it what I expected? Yes and No…It was great to feel part of a process that felt robust and clear.. Some of their recommendations may be challenging to implement but that is my job! I worried that it wasn’t as “smooth” as it might have been, but it was real and unrehearsed and we are learning.
Our constitution stipulates that the GP council meeting is held in private and the Governing Body in public. It is my understanding that this is true for all CCGs up and down the country. If the council of members make “big “ decisions though, we all agree these really should be made in public. This time we videoed the meeting and will release the video with our formal papers so anyone who wants to can watch the debate and how the decisions were reached. The company who recorded it for us joked that it would “ go viral” Somehow I doubt it! But all the way through this process we have tried to be as open and transparent as we can be about what is happening. When we received alternative options from the public we then invited them to our meetings with the clinical teams at the hospital so they could participate in the debate about those new options and whether they would be feasible. There is no national blue print for this, it is about always challenging ourselves and trying to do it better. We need to discuss with the Council that in future we need to go for full public meetings.
When I first worked in the NHS most decisions were made without any real debate, either with clinicians or with the public, based on opinion not evidence. Things are changing. WE need to continue to develop real open ways of talking, explaining, listening..it is a work in progress..
The GPs wanted to make this decision. Many smaller decisions are made by the governing body working with delegated responsibility from the GPS. However this issue felt too important and the GPs wanted to make it themselves as a group. We wanted to develop an open and transparent way to make these decisions, knowing they would be contentious and difficult., wanting to assure the public that the decisions were made thoughtfully and carefully.
As a starter the Governing Body of the CCG developed a priority framework, which was agreed and adopted by the GPs where each option was rated by every practice team in the CCG on a series of aspects: clinical effectiveness, patient experience, cost effectiveness, safety, access, sustainability and affordability. The practices used all the information we had brought together including a review of the evidence, models used around the country and internationally, economic and equality impact assessments impact of travelling , NCAT assessment and most importantly feedback from the patients and public. The practices then came together with one representative from each practice, each with delegated responsibility to speak for their practice at the meeting and feedback collectively the outcomes of the practice discussions. This was then used to develop both the shortlist for consultation and more recently to decide the outcomes of the consultation.. So for the first time the decision was made by all practices in the CCG working together. It was time consuming for us, and for the practices and could only practically be used for BIG decisions but it felt good to have such a robust method of collective decision making.
And some interesting discussions: was each practice voting on what it thought would be best for its own population or for the populations of the CCG as a whole? One of our three localities is largely unaffected by these changes but still has a role as a commissioner of service, so our job is not simply to reflect the issues for our patients in our practices but to have a wider view for all patients across our CCG. What if the discussion develops and new arguments change the overall views of the group?. Does delegated responsibility mean the rep can change their decision based on what they think their practice would do if it was sitting round the table? We agreed they could. Interestingly that was really only as issue when it came to discussing investments around supporting the changes ,not about the need for change itself.
Was it what I expected? Yes and No…It was great to feel part of a process that felt robust and clear.. Some of their recommendations may be challenging to implement but that is my job! I worried that it wasn’t as “smooth” as it might have been, but it was real and unrehearsed and we are learning.
Our constitution stipulates that the GP council meeting is held in private and the Governing Body in public. It is my understanding that this is true for all CCGs up and down the country. If the council of members make “big “ decisions though, we all agree these really should be made in public. This time we videoed the meeting and will release the video with our formal papers so anyone who wants to can watch the debate and how the decisions were reached. The company who recorded it for us joked that it would “ go viral” Somehow I doubt it! But all the way through this process we have tried to be as open and transparent as we can be about what is happening. When we received alternative options from the public we then invited them to our meetings with the clinical teams at the hospital so they could participate in the debate about those new options and whether they would be feasible. There is no national blue print for this, it is about always challenging ourselves and trying to do it better. We need to discuss with the Council that in future we need to go for full public meetings.
When I first worked in the NHS most decisions were made without any real debate, either with clinicians or with the public, based on opinion not evidence. Things are changing. WE need to continue to develop real open ways of talking, explaining, listening..it is a work in progress..
Tuesday 4 February 2014
Snow and high winds ahead!
It is hard….. so much guidance, targets, so many plans. Last year we designed our vision and we have had a year to get that off the ground. I don’t know about other CCGS but we have made a good start…investment in the community system, much improved working by health and social care staff, a real and different conversation with the public about what we all want for our area in the future and here anyway less pressure so far on the A&E front door. Some of those changes have been small I agree. Those who wish to put down CCGS laugh at us and challenge the scale of what we are doing. We have to make changes big and small. This year we have been getting people together, developing a joint sense of purpose and direction, we have been testing this out with small but significant changes, we now need to move at scale. WE have done a lot in a year. We want to hang on to that map, that vision for the future.
Yesterday I was stood on Base Brown in the Lakes. The views down across Borrowdale were spectacular and the light a little menacing but glorious. The winds were gusty and with ice under your feet and a gale that could blow you over at any moment it felt precarious but the reward was magnificent. Sometimes doing this job feels like that. So much turbulence all around. I learned to seek out the snow and avoid the ice..firm feet make you feel much safer. And I wasn’t alone and I knew my companion to be brave but not foolhardy.
I don’t remember a planning round like this one. So much to take on.. As a CCG we need to be brave we need to keep our feet steady ..rooted in the things we know are right and need to be done whilst not getting blown off course by the many targets and trajectories we are required to submit..There is a risk of getting lost in the process itself.. the worst outcome.. a lovely plan that pleases everyone and yet delivers nothing.. What ever happened to bottom up.. light touch…earned autonomy?
This is THE year.. our chance to change as much as we can as quickly as we can, building on last year.. next year we have elections, smaller management allowances, the better care fund… we have to have changed things this year , we have to be making this happen now.. this week,next week, every week…so fewer people end up in our hospitals, by next year. There are no second chances. By next year it will be too late.
Walks in the Lakes are good.. they clear your head… they give you back a sense of clarity and purpose. The physical challenges replace the intellectual ones for a few hours and allow much needed respite. I think I will be walking a lot this year…..
Subscribe to:
Posts (Atom)